Abstract

Background: Gingival recession is a common concern in patients with or
without periodontal disease. A variety of periodontal plastic surgery procedures
have been attempted in the past to treat the gingival recession deformities with
varying degrees of success. This case report describes traditional semilunar
coronally advanced flap for the treatment of recession defects on multiple
adjacent teeth.

Material and Methods: Probing depth, Clinical Attachment Level (CAL),
recession height and width were assessed at baseline and after 3 months. After
completion of phase I therapy, the esthetic surgery was planned. The technique
involved a semilunar incision made parallel to the free gingival margin of the
facial tissue, and coronally positioning the tissue over the denuded root.

Results: A reduction in the recession height, width and CAL was seen after
6 months.

Conclusion: This minimally invasive technique offers the advantage of
ease of operation as well as with minimum patient discomfort and improved
esthetics.

Keywords: Gingival recession; Esthetics; Semilunar flap

Introduction

Gingival recession is the apical migration of the junctional
epithelium with exposure of root surfaces [1]. Marginal tissue
recession not just affects gingival esthetics but also places the patient
at risk for root caries, abrasion/erosion of roots and hypersensitivity
of teeth. The etiology of gingival recession is multifactorial in nature
.Gingival anatomical factors; chronic trauma, periodontitis and
tooth alignment are considered the main conditions leading to the
development of these defects [2].

There are many procedures that have been used for the gingival
recession. The criteria for the success of root coverage procedures
is 1) gingival margin should be on the CEJ in class I and class II
recession, 2) depth should be within 2 mm, 3) no bleeding on probing
should be present, and 4) colour match with the adjacent tissue
should be there. Various treatment modalities have been reported in
literature for obtaining predictable root coverage. These procedures
include elaborate procedures like free mucosal grafts [3,4] to simple
procedures like coronally positioned flap [4,5]. It has been observed
that Class I and II gingival recession shows 100% success rate to root
coverage procedures, Class III shows 50 to 70% success, and Class
IV shows only 0 to 10% success [2]. The original semilunar coronally
repositioned periodontal flap was first described in 1986 for root
coverage of Class I and Class II recession [5].In this case report the
same technique has been described for the treatment of 2 adjacent
teeth in the aesthetic zone[5].

Materials and Methods

A 27–year-old male patient presented for routine dental
prophylaxis to the Department of Periodontics, M A Rangoonwala
Dental College and Research Centre, Pune. The patient presented
with no remarkable systemic history. Clinical examination revealed
the presence of of Millers Class I buccal recession defects on the
maxillary central incisors (Table 1) (Figure 1). Presence of adequate
width of attached gingiva was noted. Upon his smile analysis low lip
line was observed. Patient’s brushing technique was also analysed by
asking him to demonstrate the technique on the dental chair. There
was minimum amount of plaque seen and the gingiva was free of
inflammation.

Table 1: Preoperative and postoperative measurements.

Teeth number

11

21

Parameters (mm)

Baseline

6 months

Baseline

6 months

Probing Depth

1

1

0.5

0.5

CAL

3

1.5

2.5

0.5

Recession Height

2

0.5

2

0

Recession Width

3

2.5

1.5

0

Table 1: Preoperative and postoperative measurements.

Figure 1: Preoperative recession height in 11.

Figure 1: Preoperative recession height in 11.

Pre surgical procedure

Thorough scaling and root planing was performed as part of
phase1 therapy and patient was advised to use 0.2% chlorhexidine
mouth rinses for 2 weeks. Patient was also demonstrated the correct
brushing technique. After 4 weeks the patient was recalled and periodontal therapy for correction of recession was planned. The
purpose and design of the procedure was explained to the patient and
an informed consent form was signed. The width of attached gingiva
was 3 mm and was found to be adequate. The gingiva in relation to 11
and 21 demonstrated thick biotype. The approval of the Local Ethics
Committee of M. A. Rangoonwala Dental College and Research
Centre was obtained.

Surgical procedure

The presurgical measurements were assessed using UNC 15 as
shown in Table 1 (Figure 1, Figure 2) following a pre procedural rinse
with 0.2% chlorhexidine. The surgical procedure was performed under
local anaesthesia (1:200000 dilutions) §. The incisions were marked
on the tissues with a marking pencil. The frenum attachment was
gingival, hence frenotomy procedure was carried out before giving
the incision Semilunar incisions were made apical to the recession
defects of 11 and 21, starting within mucosa extending beyond the
mucogingival junction mesio-distally and arching more coronally to
terminate apical to the papillae, distal to 11 and 21. Using a number
15c blade, a split thickness dissection is made from the initial incision
line coronally connected with an intrasulcular incision, made midfacially
(Figure 3) [5]. The flap was held in its new position for 2
minutes with moist gauze. Sutures were not placed. A periodontal
dressing was placed.

The patient was prescribed a combination of Diclofenac Sodium
50mg and Paracetamol 500 mg ¥ twice daily for 3 days and 0.2%
chlorhexidine mouth rinse twice daily for 2 weeks. Patient was
advised to take soft diet and not to brush at the surgical site for atleast 2 weeks after the day of surgery.

Results

A comparison between baseline and 3 months clinical outcomes
of the patient treated by semilunar coronally positioned flap is
shown in Table 1. There was no difference observed in the probing
depth values, at the baseline and after 6 months though the clinical
attachment loss in 11 reduced from 3 mm to 1.5mm after 6 months.
In 21 the attachment loss reduced from 2mm at the baseline to
0.5mm after 6 months. A100% root coverage was seen in 21 in terms
of recession height and width as compared to 11 where 50% root
coverage was obtained after 6 months (Figure 4, Figure 5).

Figure 4: Postoperative recession height in 11 after 6 months.

Figure 4: Postoperative recession height in 11 after 6 months.

Figure 5: Post operative recession height 21 after 6 months.

Figure 5: Post operative recession height 21 after 6 months.

Discussion

Gingival recession is characterized by displacement of the
gingival margin apically from the cemento-enamel junction resulting
in root surface exposure. It is a common condition and its extent and
prevalence increase with age. A significant proportion of the adult
population is affected by this alteration which may lead to esthetic
concerns and complaints of hypersensitivity [4,5].

The primary goal of reconstructive periodontal therapy is root
coverage. Periodontal plastic surgery is defined by World Workshop in
Clinical Periodontics 1996 as surgical procedures performed to correct
or eliminate anatomic, developmental, or traumatic deformities
of the gingival [7]. Many periodontal plastic procedures have been
described in the past [8]. There is extensive data in the literature
which provides an insight into the various surgical modalities used
for the treating gingival recession. But limitations of these procedures
are lack of predictability, compromised blood supply, postoperative
discomfort, and postoperative morbidity. The traditional semilunar
coronally repositioned flap being presented has many advantages
like no tension on the flap , no shortening of the vestibule, no
sutures are needed because of the lack of tension of the tissue being
coronally positioned, minimum discomfort to the patients and
single operative site [5]. The main indication for carrying out this
technique is adequate width of attached gingiva, Class I buccal/labial
defects, where esthetics is affected and cannot be controlled by non
surgical therapy. The procedure can also be used where there has been
recession around previous full coverage restorations in the anterior
section of the mouth, where the patient has a high enough lip line
when smiling to show the denuded roots.

In the present case maxillary central incisors presented with
unesthetic Class I gingival recession with adequate width of attached
gingiva. Hence, semilunar coronally positioned flap technique was
the procedure of choice. The gingival biotype also made the technique
chosen possible.

In this case report significant improvements in clinical parameters
such as recession height and width and clinical attachment level was
observed. A100% root coverage was seen in 21 and 50% in 11 after
6 months (Figure 4, Figure 5) (Table 1). Also the technique offers
advantages like ease of performing and no need of sutures. Long-term
clinical and histological investigations are needed to confirm these
results with larger sample size.

Conclusion

Semilunar coronally positioned flap procedure is a simple
technique which has high patient acceptance and provides satisfactory
results for treating class I labial/buccal recession defects especially in
the anterior esthetic zone. Further studies with larger sample size are
needed in order to evaluate the long-term stability of the obtained
positive results.